Overview of Joint Immobilization
Musculoskeletal injuries, or injuries to the muscles, bones, and joints, are a common reason many people visit the emergency department in the United States. This includes anything from sprains and fractures to more complex joint injuries. The United States Centers for Disease Control and Prevention (CDC) and the American College of Surgeons have reported that over 42 million emergency department visits each year relate to such injuries. This represents about 14% of all visits.
Because of this, it’s very common for emergency medical services (the people who come in ambulances) to encounter people with musculoskeletal injuries before they reach the hospital. Among these, injuries to the joints (where two bones meet) can be particularly difficult to deal with because they can happen in so many different ways and it can be challenging to accurately assess and manage them right away in the field.
Joint injuries can result from many different types of accidents or incidents. They can occur from severe events like car crashes, sports injuries with high impact, or violent assaults. Equally, they can also come from low-impact events like a simple fall. Regardless of how the injury happens, it’s crucial to approach all joint injuries in the same systematic way to ensure that no important details of the injury are overlooked. This systematic approach allows for consistent care both for isolated injuries and those associated with more complex, multi-system trauma.
By providing appropriate initial stabilization and care, emergency medical service providers can help patients to avoid some short and long-term complications that can arise with joint injuries. This underscores the essential role these providers play in making sure joint injuries are managed effectively from the moment they happen.
Anatomy and Physiology of Joint Immobilization
Injuries to our muscles and bones can affect various parts of the body including our bones, joints, ligaments, or tendons. A joint is the area where two or more bones meet. The movement at these joints can vary. They basically function to allow bones to move with respect to each other. The ends of bones have a protective layer called articular cartilage and the joint itself is lubricated with a special fluid called synovial fluid. Ligaments (a tough band of fibrous tissue) provide an additional protective layer around the joint.
Joint injuries can include sprains, subluxations, dislocations, fracture-dislocations, and fracture subluxations. A sprain is when the ligaments of a joint are stretched or torn. Subluxations occur when a joint is partly dislocated but still has some contact between the bones. A dislocation is a severe form of subluxation in which the bones at a joint are completely displaced and do not contact each other. Treating a dislocated joint quickly is very important and depends on circumstances such as nerve damage, blood flow issues, and how long the dislocation occurred.
The most frequently dislocated large joint is the shoulder due to its propensity for injury and recurring dislocations. Majority of the shoulder dislocations are towards the front and the shoulder can lose its rounded appearance. In some cases, patients can experience reduced feeling over the shoulder area due to nerve injury.
Certain dislocations, like that of the hip and knee, can be very risky. For instance, hip dislocations, in which the femur or thigh bone is completely displaced from the hip socket, commonly occur due to high-impact trauma. Because the hip joint plays a role in blood supply, there can be a risk of tissue death due to lack of blood. This makes hip dislocations a critical injury that requires prompt diagnosis and treatment.
Knee dislocations also require immediate attention, especially those caused by extreme violent forces like car accidents. The danger of knee dislocations is due to the knee’s structure – a dislocation can affect the nerves and blood vessels around this area which can lead to profuse internal bleeding and the development of complication called compartment syndrome where increased pressure in an isolated muscle compartment causes insufficient blood supply. A delay of blood vessel repair after a knee dislocation can increase the risk of leg amputation. Nerve injury, which can occur in many knee dislocation cases, can lead to long-term foot drop, a condition in which a person has difficulty lifting the front part of their foot.
Fracture-dislocations, a type of injury where a joint dislocation occurs along with a fracture, are notably difficult to diagnose and manage due to limitations in examining the extent of the injury externally. It’s crucial for these injuries to be stabilised in a comfortable position and the patient should be quickly taken to the nearest medical facility.
Why do People Need Joint Immobilization
If a person experiences injuries such as sprains, partial dislocations (subluxations), complete dislocations, or bone displacement injuries (fracture-dislocations), they might need a splint. Using a splint means providing additional support to an injured area to prevent further damage. The severity of the injury guides the decision to splint, but it’s not the only factor. The goal of splinting before the patient is transported, by ambulance for example, is to prevent any further injury that can lead to increased pain or additional complications.
It’s especially significant to consider splinting for people with multiple injuries (multisystem trauma). Splinting right after the initial first aid can help stabilize the injuries, manage pain, and keep healthcare providers from missing injuries when the patient reaches the Emergency Department (ED). Choosing to use a splint should happen soon after the patient’s health history has been taken and a physical examination has been done.
When a Person Should Avoid Joint Immobilization
Put simply, joint immobilization is a way to stabilize an injured part of the body before getting to the hospital. It’s not a complicated method and it’s done quickly, usually in emergency situations, to prevent further damage during transport to the emergency department. Since this procedure is just meant to protect the injury from getting worse, there really aren’t specific conditions or reasons that would prevent using it.
Equipment used for Joint Immobilization
Prehospital splints provide a few different ways to help stabilize injuries before you can reach the hospital.
An arm sling is typically used when a shoulder injury is suspected. It’s designed like a pouch where the arm rests. The weight of your arm is distributed across your neck and upper back. This helps in minimizing the movement and possibility of further injury.
A shoulder immobilizer, on the other hand, is a device that can be easily adjusted with fasteners, and it positions the arm across the upper torso. It allows for even less movement than a sling, making it a good choice for holding a shoulder or arm steady.
For suspected knee injuries, a knee immobilizer can be used. This is a wrap-around brace that holds the knee steady from the middle of your thigh to just above your ankle. This immobilizes the knee, keeping it straight, which is particularly useful for certain knee injuries.
An ankle stirrup is a quickly applied brace usually for stable ankle injuries. It’s an air-padded wrap with fastener straps that help to hold the ankle steady when time or resources are limited.
Traction splints are typically used when fractures in long bones, like the femur, are suspected. The splint is a metal structure that runs along the injured limb, with straps to secure it. It extends past the end of the limb, and a belt at the end can be used to provide a pulling force. This imitates the effect of a stable, unbroken bone, and helps to keep the limb aligned.
Air splints function almost like inflatable casts. They are applied when deflated, and then pumped up to provide pressure and support to the immobilized area.
Vacuum splints are similar. They are deflated nylon splints filled with small foam-like beads. Once strapped in place, air is sucked out of the splint, allowing it to form around the injured area and provide rigid immobilization.
Rigid splints, as the name suggests, are made from less flexible materials, such as metal, wood or plastic. They are applied and then secured in place using bandages or straps. Different versions can be used depending on the injury, including sugar tong, volar, ulnar gutter, posterior and stirrup splints.
How is Joint Immobilization performed
When treating joint injuries, it’s really important to have a specific approach that guides every step. For example, if a joint is dislocated, the ideal situation is to reposition it before placing a splint around it. However, if repositioning the joint right away isn’t possible or causes too much pain, it might be best to hold the joint steady in a comfortable position and quickly transport the patient to reduce additional harm. Here’s a general approach that can help in these situations:
First, it’s important to protect yourself from any patient’s body fluids, or infections they might have. Then, uncover the injured area by removing any clothing or debris covering it. Check that the patient is stable before doing anything else. If they are severely injured, they should be quickly transported for further care, while ensuring their spine is immobilized. If possible, apply a splint while in transit or once they reach the care facility.
Next, have another person in your team keep the injured joint steady. This will make the patient more comfortable during the examination and when you apply the splint. The person should hold the joint above and below the injury to maintain correct position.
It’s also crucial to check the blood flow and nerve function (neurovascular status) below the injury. Joint injuries can often cause damage to nerves and blood vessels surrounding the joint. To check this, look at sensation, movement, pulse, strength, skin color, how quickly blood comes back into a pressed area, and temperature. If the area below the injury doesn’t have a pulse or is turning blue, try repositioning the joint once to help restore blood flow. If this doesn’t work or causes discomfort, put a splint on the limb and avoid touching it further. Make sure to promptly inform the hospital about the situation when the patient arrives.
Finally, use a proper device to immobilize the injury ensure it is the correct size and designed to support the joint above and below the injury. When positioning and securing the device, keep the injured joint steady. After applying the device, check the blood flow and nerve function of the area below the injury again. If your checks suggest that the device might be compromising blood flow or nerve function, loosen it and reassess the function of the extremity.
Possible Complications of Joint Immobilization
Joint immobilization can sometimes lead to certain complications, especially when it is for a long period. These problems can include muscle atrophy, which is the wasting or loss of muscle tissue, and contractures, a condition where the muscles become shorter and tighter, limiting the movement of the joint. However, these complications typically occur during long-term immobilization. In emergency situations outside the hospital, as discussed in this topic, these complications are generally minimal or non-existent.
What Else Should I Know About Joint Immobilization?
When dealing with injuries caused by trauma outside of a hospital setting, it’s vital for emergency medical service (EMS) providers to follow strict guidelines for advanced trauma support. These guidelines involve a primary review followed by a more extensive secondary review.
If a joint injury is identified, it’s essential to immobilize the joint quickly and keep it in the correct position during transport. Dealing with joint injuries can be challenging since it can be hard to differentiate between a simple dislocated joint and a more complicated joint injury in these conditions. A more complex injury could include a fracture or damage to blood vessels or nerves. To prevent further complications, every joint injury should be managed methodically.
For injuries that aren’t serious, you should immobilize the joint as found to avoid further complications. However, in situations where the patient’s position makes safe transport difficult, or if there’s a concern for damage to nerves or blood vessels further from the heart, careful repositioning of the joint may be required. The objective isn’t to reset the joint completely, rather it’s to restore function and movement to nerves and blood vessels further along, and put the limb in a more natural position.
After optimizing the joint alignment, the patient will be more comfortable and less likely to suffer more injuries to muscles, nerves, and blood vessels. Once this is done, they can fit a splint correctly to keep the joint stable for safe transport. For leg injuries, straighten the hips, slightly bend the knees, and flex the foot upwards at 90 degrees. For arm injuries, keep the shoulders level with the chest, bend elbows to 90 degrees, keep wrists neutral, and slightly bend the fingers.
Handling pain from musculoskeletal injuries effectively is also crucial. Pain relievers should be given as soon as possible. However, correctly immobilizing the joint with a splint is the best way to manage the pain. This helps restrict movement, which prevents further pain. It’s important to remember that joint injuries—whether they’re isolated or part of multiple injuries—require proper management for the best care. Correct stabilization and management can prevent serious health problems in the long term.